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Background and Objectives Evidence-based practices to manage distress behaviors in dementia (DBD) are not consistently implemented despite demonstrated effectiveness. The Veterans Health Administration (VA) trained teams to implement Staff Training in Assisted Living Residences (STAR)-VA, an intervention to manage DBD in VA nursing home settings, or Community Living Centers (CLCs). This paper summarizes multiyear formative evaluation results including challenges, adaptations, and lessons learned to support sustained integration into usual care across CLCs nationwide. Research Design and Methods STAR was selected as an evidence-based practice for DBD, adapted for and piloted in VA (STAR-VA), and implemented through a train-the-trainer program from 2013 to 2018. Training and consultation were provided to 92 CLC teams. Evaluation before and after training and consultation included descriptive statistics of measures of clinical impact and survey feedback from site teams regarding self-confidence, engagement, resource quality, and content analysis of implementation facilitators and challenges. Results STAR-VA training and consultation increased staff confidence and resulted in significant decreases in DBD, depression, anxiety, and agitation for Veterans engaged in the intervention. Implementation outcomes demonstrated feasibility and identified facilitators and barriers. Key findings were interpreted using implementation frameworks and informed subsequent modifications to sustain implementation. Discussion and Implications STAR-VA successfully prepared teams to manage DBD and resulted in improved outcomes. Lessons learned include importance of behavioral health–nursing partnerships, continuous engagement, iterative feedback and adaptations, and sustainment planning. Evaluation of sustainment factors has informed selection of implementation strategies to address sustainment barriers. Lessons learned have implications for integrating team-based practices into system-level practice. [ABSTRACT FROM AUTHOR]

Objectives This paper examines the family ties of older adults in the United States and how they are associated with mental health and social activity. We compare older adults with 4 types of family ties: adults "close" to family in proximity and social network, "kinless" older adults without a partner or children, "distanced" adults who live far from close kin, and "disconnected" older adults who do not report kin in their social network or do not report a location for some kin. Methods Using pooled data from the National Health and Aging Trends Study 2015–2019 for older adults aged 70 and older (N = 24,818 person-waves), we examine how family ties are associated with mental health and social activity, and whether lacking family is tied to poor well-being because older adults' needs are not being met. Results Kinless older adults and disconnected older adults have poorer outcomes (lower mental health scores and less social activity), compared to those close to their family. These findings suggest that both the presence and quality of the connection, as measured here via both location and social network, are critical for understanding which older adults are "at risk." Older adults who were not geographically proximate to their close kin (i.e. distanced) were not disadvantaged relative to those close to their families. Unmet needs do not help explain these patterns. Discussion Our results highlight that family ties are important for older adults well-being, not just through their existence but also their quality and strength. [ABSTRACT FROM AUTHOR]

Objective To study the role of gender and marital status as risk factors for nursing home entry in the United States. Method The paper uses data from the Health and Retirement Study, a nationally representative survey of the older population in the United States. Multivariate logit models of the risk of nursing home entry over a 2-year follow-up period were estimated for noninstitutionalized individuals over the age of 65. A multiple imputation procedure was used to explore the sensitivity of the results to alternative assumptions about the data-generating process of missing outcome values. Results In an analysis based on complete observations, women exhibited the same risk of nursing home entry as men (risk ratio [RR] = 1.01; CI: 0.90, 1.13). However, after expanding the sample to include information on nursing home use for individuals who died during the follow-up period, women were found to have a statistically lower risk of nursing home entry (RR = 0.85; CI: 0.79, 0.92). The latter result was robust to alternative assumptions about the nature of missing data. The type of sample used in the analysis did not affect the conclusions regarding the role of marital status. Divorced and widowed individuals were found to be at higher risk of nursing home admissions than married individuals in all specifications. Discussion The findings clarify the role of gender as a predictor of nursing home admissions and may provide useful prognostic information for clinicians and caregivers regarding nursing home entry risk. The study also sheds light on how conclusions about predictors of nursing home risk obtained from prospective studies with long follow-up periods can be affected by the treatment of missing outcomes due to death or attritions. [ABSTRACT FROM AUTHOR]

Introduction: Many medical schools in the United States are introducing leader and leadership curricula. However, there is a large gap regarding how to assess leader performance during undergraduate medical education. With the guidance of a conceptual framework, leadership assessment measures can be developed, learners can make expected improvements in performance over time, and assessment measures can be used in relevant, applied, medical teaching settings. Uniformed Services University (USU) medical students are educated to become healthcare leaders who can perform effectively in various settings. Medical students are assessed on multiple occasions for elements of leader performance during "Operation Bushmaster" - the capstone military medical field practicum event for fourth year medical students - by experienced faculty. A conceptual framework guides the assessment approach for leader performance during Bushmaster. The USU Leader and Leadership Education and Development program developed an assessment tool to measure student leader performance used in a military medical field practicum. The present paper examines whether: (1) leader performance can be measured at Bushmaster; (2) leader performance changed during Bushmaster; (3) leader performance elements are related to each other; and (4) overall leader performance is related to other medical academic performance.Materials and Methods: Trained faculty assessed students' leader performance. Data from three cohorts of USU medical students (N = 509) were collected. All data were collected, compiled, deidentified, and analyzed with approval from the USU Institutional Review Board (Protocol number: KM83XV). Descriptive statistics, repeated measures t-tests, trend analyses, and correlation analyses were performed.Results: Data were available from 483/509 [95%] students. Results revealed that: (1) average leader performance was satisfactory; (2) overall leader performance and performance on each of the major elements of leader performance significantly improved over the course of Bushmaster; (3) major elements of leader performance were significantly correlated with each other and with overall leader performance; (4) leader performance was not correlated with students' performance on the MCAT total score or USMLE Step exam scores.Conclusion: With the guidance of a conceptual framework, the assessment tool was used to assess leader performance in a relevant, applied, medical teaching setting. The findings of this study indicate that leader performance can be measured. Additionally, leader performance appears to be a separate skillset from medical academic performance and both types of performance can be taught and developed. This was a retrospective correlation study and was conducted during a military medical field practicum at a single institution. Gathering additional validity evidence of the assessment tool is needed. With additional validity evidence, the assessment tool could be applied to other medical exercises in different settings and help with the assessment of leader performance beyond medical school. [ABSTRACT FROM AUTHOR]

Context/problem: Comparative analysis of relative and absolute mortality differentials between socioeconomic groups are now available. These show consistently increasing relative increases in mortality differentials but complex trends in absolute mortality differentials. Objective: This paper provides an analysis of relative and absolute trends in mortality by cause of death and socioeconomic group (SEG) from 1984 to 2008 among men and active women aged 30-64 years in Ireland and compares these results with recent European and US studies to give an overview of trends. Methods: This paper uses mortality data from the Irish Central Statistics Office from 1984 to 2008 to calculate standardized death rates by age, sex, socioeconomic status and cause of death showing trends in SEG inequalities in mortality in Ireland. These show which specific causes of death are driving all-cause mortality trends. Results: SEG differentials in all-cause mortality among men and women have been increasing since the 1980s. Some of this increase reflects larger falls in cardiovascular causes among advantaged groups, but the trend is largely accounted for by increasing inequalities in mortality in digestive, neoplasm and external causes of deaths. Conclusions: These findings are in line with international findings that show that socioeconomic differentials in digestive, neoplasm and external cause deaths are driving general socioeconomic differentials in all-cause mortality. External cause deaths may have been influenced by levels of economic activity, particularly in construction, during the economic boom among manual workers. Furthermore, deaths from digestive diseases during the 1990s and 2000s may well be the result of increases in liver disease associated with excessive alcohol consumption. [ABSTRACT FROM AUTHOR]

Background: Tier 1 exposure tools recommended for use under REACH are designed to easily identify situations that may pose a risk to health through conservative exposure predictions. However, no comprehensive evaluation of the performance of the lower tier tools has previously been carried out. The ETEAM project aimed to evaluate several lower tier exposure tools (ECETOC TRA, MEASE, and EMKG-EXPO-TOOL) as well as one higher tier tool (STOFFENMANAGER®). This paper describes the results of the external validation of tool estimates using measurement data. Methods: Measurement data were collected from a range of providers, both in Europe and United States, together with contextual information. Individual measurement and aggregated measurement data were obtained. The contextual information was coded into the tools to obtain exposure estimates. Results were expressed as percentage of measurements exceeding the tool estimates and presented by exposure category (non-volatile liquid, volatile liquid, metal abrasion, metal processing, and powder handling). We also explored tool performance for different process activities as well as different scenario conditions and exposure levels. Results: In total, results from nearly 4000 measurements were obtained, with the majority for the use of volatile liquids and powder handling. The comparisons of measurement results with tool estimates suggest that the tools are generally conservative. However, the tools were more conservative when estimating exposure from powder handling compared to volatile liquids and other exposure categories. In addition, results suggested that tool performance varies between process activities and scenario conditions. For example, tools were less conservative when estimating exposure during activities involving tabletting, compression, extrusion, pelletisation, granulation (common process activity PROC14) and transfer of substance or mixture (charging and discharging) at nondedicated facilities (PROC8a; powder handling only). With the exception of STOFFENMANAGER® (for estimating exposure during powder handling), the tools were less conservative for scenarios with lower estimated exposure levels. Conclusions: This is the most comprehensive evaluation of the performance of REACH exposure tools carried out to date. The results show that, although generally conservative, the tools may not always achieve the performance specified in the REACH guidance, i.e. using the 75th or 90th percentile of the exposure distribution for the risk characterisation. Ongoing development, adjustment, and recalibration of the tools with new measurement data are essential to ensure adequate characterisation and control of worker exposure to hazardous substances. [ABSTRACT FROM AUTHOR]

Objectives: Heat stress exposure limits based on wet-bulb globe temperature (WBGT) were designed to limit exposures to those that could be sustained for an 8-h day using limited data from Lind in the 1960s. In general, Sustainable exposures are heat stress levels at which thermal equilibrium can be achieved, and Unsustainable exposures occur when there is a steady increase in core temperature. This paper addresses the ability of the ACGIH® Threshold Limit Value (TLV®) to differentiate between Sustainable and Unsustainable heat exposures, to propose alternative occupational exposure limits, and ask whether an adjustment for body surface area improves the exposure decision. Methods: Two progressive heat stress studies provided data on 176 trials with 352 pairs of Sustainable and Unsustainable exposures over a range of relative humidities and metabolic rates using 29 participants wearing woven cotton clothing. To assess the discrimination ability of the TLV, the exposure metric was the difference between the observed WBGT and the TLV adjusted for metabolic rate. Conditional logistic regression models and receiver operating characteristic curves (ROC) along with ROC's area under the curve (AUC) were used. Four alternative models for an occupational exposure limit were also developed and compared to the TLV. Results: For the TLV, the odds ratio (OR) for Unsustainable was 2.5 per 1°C-WBGT [confidence interval (CI) 2.12-2.88]. The AUC for the TLV was 0.85 (CI 0.81--0.89). For the alternative models, the ORs were also about 2.5/°C-WBGT, with AUCs between 0.84 and 0.88, which were significantly different from the TLV's AUC but have little practical difference. Conclusions: This study (1) confirmed that the TLV is appropriate for heat stress screening; (2) demonstrated the TLV's discrimination accuracy with an ROC AUC of 0.85; and (3) established the OR of 2.5/°C-WBGT for unsustainable exposures. The TLV has high sensitivity, but its specificity is very low, which is protective. There were no important improvements with alternative exposure limits, and there was weak evidence to support metabolic rate normalized to body surface area. In sum, the TLV is protective with an appropriate margin of safety for relatively constant occupational exposures to heat stress. [ABSTRACT FROM AUTHOR]

Objectives. Little is known about how exposure to a combination of infectious and chronic conditions throughout the lifecourse could impact disability in old age. This paper compares 2 cohorts of adults who have aged under very different country contexts by contrasting disability transitions among elders in Mexico with elders in the United States. Methods. Data comes from the Mexican Health and Aging Study (MHAS) and the U.S. Health and Retirement Study (HRS). Estimated probabilities of 2-year transitions among disability states and mortality are presented for adults aged 50 and older. Results. The levels of disability prevalence and 2 year transitions are consistent with a higher rate of disability for the United States compared to Mexico. In 2-year transitions, the U.S. sample was more likely to transition to a disabled state or increase the number of disabilities than the Mexican counterparts, while Mexicans are more likely to move out of disability or reduce the number of disabilities reported. Discussion. The findings suggest that the current rate of disability in old age is lower for a less developed country compared with a developed society. We discuss implications, possible explanations, and likely future scenarios. [ABSTRACT FROM AUTHOR]

The most recent internationally widespread disease outbreak occurred during the flu season of 2009 and 2010. On April 2009, the first cases of influenza A (H1N1) (Popularly called, Swine Flu) were confirmed in the USA and UK following a novel virus that was first identified in Mexico. As the virus spread rapidly, the risk of morbidity and mortality increased in several countries. In this paper, we rely on the social cognitive theory of risk to assess the willingness of the US public to comply with vaccination and reduce the risk of sickness and death from the flu. We conduct a secondary data analysis of the Pew Research for the People and Press October 2009 and investigate the factors associated with willingness to take the swine flu vaccine (n = 1000). The findings indicate that the decision to take the swine flu vaccination was highly polarized across partisan lines. Controlling for education, income and demographic factors, the likelihood of taking the vaccine was associated with party identification. Individuals that identified themselves as Democrats were more likely to be willing to take the swine vaccine than individuals that identify themselves as Republicans and Independents. Confidence in the ability of the government to deal with the swine flu crisis seems to explain party identification differences in the willingness to take the vaccine. The implications of the findings are discussed. [ABSTRACT FROM AUTHOR]

“Feature Article: This paper is a based on the Joseph T. Freeman Award lecture given at the Annual Meeting of The Gerontological Society of America held in New Orleans, Louisiana, in November, 2013:”Among older persons, disability in activities of daily living is common and highly morbid. The Precipitating Events Project (PEP Study), an ongoing longitudinal study of 754 initially nondisabled, community-living persons, aged 70 or older, was designed to further elucidate the epidemiology of disability, with the goal of informing the development of effective interventions to maintain and restore independent function. Over the past 16 years, participants have completed comprehensive, home-based assessments at 18-month intervals and have been interviewed monthly to reassess their functional status and ascertain intervening events, other health care utilization, and deaths. Findings from the PEP Study have demonstrated that the disabling process for many older persons is characterized by multiple and possibly interrelated disability episodes, even over relatively short periods of time, and that disability often results when an intervening event is superimposed upon a vulnerable host. Given the frequency of assessments, long duration of follow-up, and recent linkage to Medicare data, the PEP Study will continue to be an outstanding platform for disability research in older persons. In addition, as the number of decedents accrues, the PEP Study will increasingly become a valuable resource for investigating symptoms, function, and health care utilization at the end of life. [ABSTRACT FROM PUBLISHER]

Skin color has been proposed to contribute to race-based health disparities in the United States because of differences in ultraviolet (UV) light–induced vitamin D synthesis. The prediction of this hypothesis, herein named the UVD hypothesis, is that racial disparities in health outcomes are correlated with UV light availability. This paper investigates whether UV light availability is associated with disparities in the rates of low birth weight (LBW) and preterm birth (PTB) between whites and blacks, because these outcomes are thought to be influenced by vitamin D status and to shape disease risk in later life. Data on LBW and PTB from 2007 (n = 2,825,620 births) were compared with data on UV light exposure across the United States. Contrary to the predictions of the UVD hypothesis, LBW and PTB rate disparities were greatest in states with the highest UV light exposure. Notably, income inequality was positively and significantly related to LBW and PTB disparities, even after controlling for UV light availability. The results of this analysis demonstrate that there is a significant environmental gradient in racial disparities in birth outcomes in the United States, but other social or environmental factors associated with living in the southern United States are likely stronger contributors to disparities in birth outcomes than UV light–induced vitamin D status. [ABSTRACT FROM PUBLISHER]

Background. To date, there has been no attempt to describe or compare physical therapy as practiced globally, nor any evidence that an international data set exists to support this effort. It is known that research evidence can be used in strategic and tactical ways, especially within the highly politicized context of the policy arena. The International Private Practitioners Association recognized the potential value a global evidence base could have in influencing policy and supporting professional development in a number of countries, yet it lacked a mechanism to achieve these aims. Objectives. The purposes of this study were: (1) to identify and test an international data set, definitions, and means of data collection and (2) to establish views in relation to the value of international collaborations. Design. A mixed, prospective design was used in the study. Method. Phase 1 (2006-2007) involved the development of a data set, definitions, and Web-based and paper-based data collection options involving 98 physical therapists from 68 physical therapy practices in 7 countries. Phase 2 (2008-2009) involved testing of the data set in 34 practices involving 3,195 patient episodes and included physical therapist feedback of experience, local relevance of the data set, and value of international collaborations. Results. Testing confirmed the relevance and reliability of the data set and definitions and a preference for Web-based data collection (74.0%). Physical therapist feedback supported these findings. Most respondents (60.0%-100.0%) reported the value of further international collaborations for their profession nationally or internationally. Limitations. Although a true international collaboration, the limited sample size should be recognized. Conclusions. It is possible to develop an agreed-upon international data set and means of data collection. Testing appears to support its acceptability and relevance for use in practice. Participants highly valued the opportunity to undertake international collaborations that may benefit their profession nationally and internationally. Further testing and use of the data set are advocated before final validation is sought. [ABSTRACT FROM AUTHOR]